198603402-4-18-2024-28-AS-CWOG-D4FRSA-20240418131626

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603402
Report Date: 04/18/2024
Date Signed: 04/18/2024 01:17:03 PM

Document Has Been Signed on 04/18/2024 01:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	RHEMA CARE GROUP LLC - HOLLY OAK DRIVE		FACILITY NUMBER:	198603402
ADMINISTRATOR/ DIRECTOR:	IRHIA, BLESSING		FACILITY TYPE:	735
ADDRESS:	1820 E HOLLY OAK DRIVE		TELEPHONE:	(626) 426-5904
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 4		CENSUS: 4	DATE:	04/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	John Wilson		TIME VISIT/ INSPECTION COMPLETED:	01:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Wong conducted the unannounced Annual Inspection and met with Administrator John Wilson who allowed the entry of the facility and explained the reason of today's visit and will be using the Compliance And Regulatory Enforcement (CARE) Tools to inspect the facility. The facility is licensed for age range 18 through 59 and ambulatory only. The facility is vendorized as a Specialized home with San Gabriel Pomona Regional Center. The following domains were reviewed during today's annual required visit which included: infection control, physical plant and environmental, operational requirements, staffing, personnel records-training, client rights- information, client records-incident reports, food service, health related services, incidental medical services, disaster preparedness and emergency intervention. 1. Infection Control: The facility has an approved infection control plan and sufficient PPE supplies in place. The facility staff continue to practice hand washing and using gloves in the facility. Staff would clean and disinfect once a day or more often for high touched surfaces area. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: dining area, living room, kitchen, four clients bedrooms and two client's bathrooms and a detached garage. Each client's bedroom has one bed, chair, drawer, night stand and required furniture and beddings and sufficient lighting and closet space. The two client's bathrooms are clean, sanitary and in a good working condition. The two client's bathrooms hot water temperature were tested from 116 degrees F to 120 degrees F. which are within the Title 22 regulation. All the kitchen appliances are working properly. All the sharp knives and utensils are stored and locked in the cabinet next to the dining table. The cleaning supplies are stored and locked in the cabinet next to the bathroom#2. The extra personal hygiene products are stored and locked in the cabinet next to the bathroom and the hallway cabinet. The extra linen and towels are stored in the hallway cabinet. LPA inspected the carbon monoxide detectors and they are all interconnected and they are working well. The facility has a telephone services on the premises. The facility has a hallway night and staff will turn on the light during the night time so client can access the non-private bathroom. The passageway, walkway and patio are free of obstruction.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RHEMA CARE GROUP LLC - HOLLY OAK DRIVE	FACILITY NUMBER: 198603402
	VISIT DATE: 04/18/2024

NARRATIVE

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3. Operational Requirements: The facility is approved for four ambulatory clients and currently all four clients in the facility are ambulatory. The facility has a covered patio with table and chairs for client to utilized the outdoor activity. The facility also would let client to participate or attend community activities if there's a chance or opportunity.

4. Staffing: The facility has a sufficient staff to provide care and supervision to clients in care. LPA reviewed the NOC shift staff and has the required facility emergency procedure training.

5. Personal Records-Training: The facility staff files are stored and locked in the black cabinet next to the dining table. All the staff in the facility are over 18 years old, background check cleared and associated with the facility. LPA reviewed four staff files and they all have the required documents including health screening, TB Test and updated First Aid Certificate and CPI Certificate and required training hours. The administrator is John Wilson and his administrator certificate expire on 8/8/2025 and the administrator also has the updated HIV and TB training in place.

6. Client's right: Currently there's no client in the facility required any postural support. Also the facility has at least one internet access device with internet service for clients to use.

7. Food service: Currently there's no client in the facility required modified diet. The facility has sufficient food supply for two days perishable and seven days non- perishable. All the food in the facility are stored properly. The facility would provide at least three meals and snacks per day to client.

8. Client's Record-Incident Reports: The client's files are stored and locked in the black cabinet next to the dining table. LPA inspected all four clients' files and they all have the required documents including: face sheet, admission agreement, physician report, Individual Program Plan (IPP), TB test result, medication list and ambulatory status.

9. Health Related Services: All the client's medication in the facility are centrally stored in the long cabinet next to the dining table. LPA inspected all four (4) clients medication and they are all seemed accurate and updated and they all have 30 days supply of medication. The facility also assist client with all the medical and dental appointments.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RHEMA CARE GROUP LLC - HOLLY OAK DRIVE	FACILITY NUMBER: 198603402
	VISIT DATE: 04/18/2024

NARRATIVE

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10. Incidental Medical Services: Currently there's no client in the facility has any restricted health condition or prohibited health condition.

11. Disaster Preparedness: The facility has an updated emergency disaster plan dated on 5/2/23 and the last fire and disaster drill was conducted on 3/11/24. All the staff also received annual emergency disaster training. The facility also has three temporary shelter location in place.

12. Emergency Intervention: The facility does not use restraint with clients but they will use Emergency Intervention Techniques and all staff are CPI trained.

No Deficiencies were observed during the annual inspection.

Exit Interview conducted and a copy of the report was provided to the administrator John Wilson.

(Due to the clients are all in day program or in the community with the facility staff, LPA was not able to interview clients during the annual inspection.)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

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